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Serbia: on AIDS, politics and a culture of fear

Homophobia in Serbia prevents many gay men with HIV from seeking medical help [AFP]

Marko was in his late forties when he died from acquired immunodeficiency syndrome (AIDS). AIDS developed as a result of an advanced infection with human immunodeficiency virus (HIV) that was left untreated. Marko (not his real name) died alone in his home in Belgrade, without seeking the publicly-funded and life-saving treatment that he was entitled to. HIV gravely damaged his immune system and he became vulnerable to many opportunistic infections over a span of 3 years. Marko's death was slow and painful, as is usually the case with untreated HIV/AIDS. However, his progression to full-blown AIDS and ultimate death was not a result of mere HIV infection. Marko's death was a consequence of complex societal forces in Serbia.

HIV in Serbia

More than three decades into the battle against HIV, intolerance and discrimination remain major roadblocks to HIV prevention and treatment. Terror and shame drive people underground and discourage them from using services such as free HIV testing or free condoms. In Serbia, intolerance is catalysing the spread of HIV among men, who account for the vast majority of newly diagnosed cases.

According to a 2012 report[Sr] from the Serbian Institute of Public Health, for every HIV-positive woman in the country, there were more than 11 HIV-positive men. The same report estimates that the leading route of HIV transmission in the country is male-to-male contact, officially accounting for 66 percent of newly diagnosed cases in 2012. This figure is most likely a gross underestimate,given the fears around disclosing sexual preferences among many men.

HIV infections among Serbian men have flourished in an environment of violent intolerance towards gay and bisexual populations, coupled with insufficient protections from the state. A 2010 public opinion surveysuggested that two-thirds of citizens consider homosexuality to be an illness and more than half believe that state institutions should work on suppressing homosexuality.

Belgrade Pride Parades were only organised in 2001[Sr] and 2010, with both resulting in massive civil unrest andviolence. The state banned Pride Parades altogether in the past two years, under the rationale that they presented a threat to public safety. Meanwhile NGOs report alarming levels of violence towards Serbian gays and lesbians, with a poll suggesting that 90 percent of them know of cases of violence against people due to non-heterosexual orientation, and 70 percent report being victims of violence themselves.

This is not unique to Serbia, experiences of homophobia and discrimination based on homosexual behaviour have been linked to elevated risks of HIV infection in China and the US.

Fear of homophobia can also press closeted men to have secret relationships with other men while maintaining female partners. They might also be reluctant to suggest condom use to their female partners as doing so could raise suspicion. In 2012, a survey of men who have sex with men[Sr] in the Serbian city of Novi Sad indicated that more than half of the respondents also had sex with women in the previous year. Of those, only half consistently used condoms with their female partner(s). These patterns raise serious public health concerns, since they may imply that there is a "bridge" that facilitates the spread of the virus from the "high risk population" to the "general population".

Turmoil and populism

A discussion of intolerance in Serbia would be incomplete without a consideration of the country's recent history. It has been argued that nationalist masculinity is "drawn on in times of social and political crisis in order to architect a sense of continuity, agency and belonging". Many young Serbs, including myself, have only known of "times of social and political crisis" in our country.

We were born in the 1980s, and were just becoming aware of the world around us when the Yugoslav wars started, with propaganda feeding us images that glorified warlords. We were students during a time when not going to school was normal due to strikes, lack of heating, and other events such as the 1999 bombing. We lacked parental monitoring and attention because our parents were overwhelmed with making ends meet. Few traveled due to visa and financial restrictions. The world as we knew it was Serbia, and it equated with chaos.

Despite evidence of cost-effective programmes that have been shown to work elsewhere, Russian authorities and the Orthodox Church oppose their implementation on 'moral' grounds.

Today, prejudiced rhetoric of populist politicians continues to confuse our youth. One example is the official wedding of two giraffes in the City of Jagodina local zoo, organised by the city's mayor, a member of the ruling party coalition. In his address to media, the mayor drew parallels between the giraffe wedding and the banned Pride Parade in Belgrade, adding that this wedding was "important for those who think differently and [his] message to them is that it is a male and a female that should enter a marriage, and not two males". Many elementary school students whose classes were cancelled for the occasion attended the event.

Regional epidemic

Serbia is among the countries in Eastern Europe which still have relatively low HIV prevalence. However, in the past decade, other countries in the region - especially from the former USSR - have witnessed a sharp rise in the number of new infections due to failures of the authorities to address the problem.

Accounting for the majority of the region's HIV burden, Russia is experiencing an epidemic that is driven by unsterile intravenous drug use and conservative policies. Although the main factor responsible for new infections in Russia is different from Serbia's, there is a lot that we can learn from the Russian government's mistakes in an attempt to prevent reaching its magnitude of HIV rates.

Despite evidence of cost-effective programmes that have been shown to work elsewhere, Russian authorities and the Orthodox Church oppose their implementation on "moral" grounds. One public health approach involves heroin substitution therapy, where drug users are supplied with a replacement drug, such as methadone, in a supervised clinical setting.

These evidence-based programmes have not only been shown to be an effective HIV prevention strategy, but they also substantially reduce illicit drug use and death from overdose and suicide. Yet, the 2010-2020 Russian drug strategy bans such programmes and use of methadone remains illegal in the country. Intolerance is also illustrated by Russia's funding priorities. Although injecting drug users make up 83 percent of the country's HIV cases, less than 1 percent of funding for HIV-related initiatives is targeted towards prevention for this at-risk group.

Similar stigmatising attitudes contributed to Marko's death in Belgrade. He did not lose his life to HIV alone, rather, intolerance and homophobia compromised his health and willingness to seek treatment. No single prescription can stop the spread of HIV in Serbia - or elsewhere - but evidence from around the world tells us that intolerant attitudes and discriminatory policies fuel HIV infections and AIDS-related deaths.

Condom distribution and provision of health services are a must, but they are not sufficient to significantly reduce the spread of HIV and AIDS-related deaths in Serbia. We need people to use condoms and health services. For this to happen, the roots and causes of homophobia and other forms of intolerance in Serbia and the rest of Eastern Europe must be addressed. Let that be our 2013 World AIDS Day resolution.

Marija Pantelic is an independent writer from Serbia. She is pursuing a PhD at the Department of Social Policy and Intervention, University of Oxford.